刘建明 陈雪霞 谭智 谭妙莲 刘霞 陈虹 刘大钺

    ·研究与实践·

    FOCUS-PDCA循环管理对提高医务人员手卫生依从性的效果分析

    刘建明 陈雪霞 谭智 谭妙莲 刘霞 陈虹 刘大钺

    目的 探讨FOCUS-PDCA循环管理在提高医护人员手卫生依从性中的作用，为医院做好手卫生管理提供依据。方法 以三级甲等综合性医院复评为契机，运用FOCUS-PDCA循环分析我院医务人员手卫生现状，并据此制定、落实持续改进措施，以措施实施后医护人员手卫生依从性改进情况作为的效果评价指标。结果 医务人员手卫生知晓率、执行率和正确率在干预后均较有显著提升，医院感染及手术部位感染发生率与同期相比显著下降。 结论 FOCUS-PDCA循环方法有利于推动手卫生管理的持续改进，可有效提高医务人员手卫生意识和依从性，有助于降低医院感染发生。

    医院评审；FOCUS-PDCA循环；手卫生；医院感染

    【Abstract】Objective The paper aims to explore into effect of FOCUS-PDCA cyclical management on improving the compliance of hand hygiene of medical staff and provide basis for the hospital to carry out hand hygiene management.Method Review of Grade III Class A Hospital is regarded as an opportunity，FOCUS-PDCA cycle is used to analyze present situation of hand hygiene of medical staff in our hospital and continuous improvement measures are formulated and implemented accordingly；improvement of the compliance of hand hygiene of medical staff after implementation of measures are deemed to be effect evaluation indexes.Result Medical staff's hand hygiene awareness rate，implementation rate and accuracy are greatly improved after interference；incidence rates of hospital infection and surgical site infection have significantly decreased compared with the same period.Conclusion FOCUSPDCA circulation approach is in favor of continuous improvement of hand hygiene management and could effectively enhance medical staff's hand hygiene awareness and compliance so as to reduce occurrence of hospital infection. ......